While MSAs often dominate conversations surrounding MSP compliance, conditional payments occur far more frequently and can present equally significant exposure if not properly addressed. One common misconception is that the resolution of conditional payments has become a straightforward, automated exercise. In reality, recent operational changes involving recovery contractors have introduced new challenges when attempting to dispute and appeal unrelated charges.

CMS administers the conditional payment recovery process through two contractors: the Benefits Coordination & Recovery Center (BCRC), which manages Medicare beneficiary information and case setup activities, and the Commercial Repayment Center (CRC), which is responsible for identifying and recovering conditional payments related to settlements, judgments, awards, and other payments. Following a recent transition with CRC operations, many stakeholders have observed a noticeable increase in the inclusion of unrelated or improperly associated medical charges within Medicare’s demands.

In October 2025 Machinify acquired Performant Healtcare, Inc. for $670M. Performant held the CRC contract, allowing it to perform ORM recovery on behalf of Medicare. Post-acquisition, we’ve seen some changes to the way the CRC operates. This can delay resolution or, in most cases, simply increase the amount of material that must be submitted with a corresponding dispute and appeal. 

In particular, we have seen a growing number of recovery demands that include unbundled charges or treatment that appear unrelated to the claim. While disputes and appeals remain effective tools, obtaining favorable outcomes has increasingly required more robust documentation and corroborating evidence than in years past.

The good news is that these charges can still be removed when parties are proactive and thorough in supporting their position.

Here, we offer five tips for successful conditional payment disputes and appeals:

1.    Provide detailed medical records, not just summaries. Treatment notes, operative reports, and physician documentation are often more persuasive than broad explanations regarding unrelated care – particularly when there’s a possibility that the treatment could actually be related based purely on the provider or codes

2.    Submit claim-specific documentation early. Denial letters, accepted body parts, stipulations, and settlement agreements can help demonstrate the scope of the claim and identify unrelated treatment.

3.    Explain why the charge is unrelated. A simple statement that treatment is unrelated with a corresponding reference to the Section 111 data may no longer be sufficient. Providing a concise narrative connecting the medical evidence to the disputed charge can improve outcomes.

4.    Corroborate with multiple sources when possible. Combining medical records, carrier documentation, payment histories, and physician opinions can strengthen the dispute package and reduce follow-up requests.

5.    Expect additional scrutiny and build your timeline accordingly. Requests for additional information and prolonged review periods have become more common, making early identification and resolution of conditional payments increasingly important.

It’s important to note that it appears that nothing has changed in the CRC’s statement of work. Simply put, these changes reflect the CRC’s new evaluation of the information necessary to corroborate a conditional payment dispute or appeal. The CRC contractor is paid what is effectively a contingency fee on the amount that it’s able to recover from claims payers.

As CMS’ recovery processes continue to evolve, successful conditional payment resolution requires more than simply identifying unrelated charges, it requires building a well-documented record that clearly demonstrates why those charges should not be recovered. While the process may be more demanding than it once was, a proactive and evidence-driven approach continues to produce positive results.

Our advice in general remains the same – assume that the charges are unrelated to your underlying workers’ compensation or no-fault claim and marshal whatever material you can to effectively dispute all charges. If the conditional payment notice or demand is complicated, confusing, or time-consuming, contact a professional to address the matter.

ExamWorks Compliance Solutions handles tens of thousands of conditional payment claims per year, eliminating millions of dollars in improper recovery per month.  Our team of experts is available to assist you with the conditional payment recovery process. ECS provides a range of recovery services including complex handling of traditional Medicare, Medicare Advantage, and Prescription Drug Plan liens.